An alternative approach to repair of giant paraesophageal hernia in selected patients with minimal history of reflux: Analysis of outcomes in more than 100 patients

Abstract

Objectives

Laparoscopic repair of giant paraesophageal hernia (LGPEHR) is a complex operation and typically includes an antireflux procedure (ARS); however, some patients without a history of reflux may be able to avoid an ARS. The objective of this study was to evaluate an alternative approach for giant paraesophageal hernia (GPEH) repair with restoration of the normal anatomy and an extended gastropexy in selected patients with minimal reflux symptoms.

Methods

Patients who underwent GPEH repair with an extended gastropexy were reviewed retrospectively. The procedure was not a “simple gastropexy.” The LGPEHR included complete mediastinal dissection, hernia-sac reduction that restored anatomic intra-abdominal positioning of the stomach with careful preservation of the crura and vagal nerves, and tension-free crural repair. Then, an extended gastropexy was performed by placing a series of horizontal mattress sutures along the line of the short gastric vessels to the left crus and diaphragm. Perioperative outcomes, symptomatic improvement, recurrence, need for reoperation, and quality of life (Gastroesophageal Reflux Disease-Health-Related Quality of Life questionnaire) were evaluated.

Results

A total of 114 patients (median age 77.4 years) underwent GPEH repair with gastropexy (elective n = 81; urgent/emergent n = 33). Perioperative complications occurred in 11 patients (9.6%). Dysphagia improved significantly (P < .01), and the median Gastroesophageal Reflux Disease-Health-Related Quality of Life score after GPEH repair was 2 (considered excellent). Imaging follow-up was performed at a median time of 14 months, with recurrence of hiatal hernia in 4 patients; 2 required reoperation.

Conclusions

LGPEHR with restoration of the normal anatomy and an extended gastropexy appears to be safe with good outcomes when key elements of repair are incorporated. If further validated, this option may be considered in selected high-risk patients who are not candidates for an ARS.